Clinical Reimbursement ManagerWhat will I do as a Clinical Reimbursement Manager with Keswick?- Oversees clinical reimbursement operations and ensures the collection of information (initial and ongoing) for the Minimum Data Set (MDS). Ensures the MDS coordinator team works with the nursing department for a comprehensive nursing assessment of the resident/patient health status.
- Demonstrates expertise in the completion of the MDS to capture services provided and facilitate optimal reimbursement. Ensures the appropriate MDS is completed timely for the various circumstances related to admission and quarterly assessments, interrupted stay, change of condition, etc.
- Meets with resident/patient in-person to collect information (initial and ongoing) for the Resident Assessment Instrument (RAI) and provides a comprehensive nursing assessment of the resident/patient health status that will be used in addressing anticipated changes in resident/patient condition.
- Completes comprehensive resident assessment (initial, quarterly, annual); ensures that documentation meets requirements of Keswick and regulatory agencies and is sufficient to substantiate reimbursement for Keswick services
- Completes MDS and MMDS according to established policies and procedures; locks and transmits to the State
- Performs assessments, including quarterly Braden Scale, quarterly falls, quarterly and annual side rail, and quarterly pain assessment
- Works to identify coding that reflects the full patient condition and captures all appropriate ancillary and rehab conditions.
- Assures that documentation meets the requirements of Keswick and regulatory agencies and is sufficient to support MDS coding as well as to substantiate reimbursement for Keswick services.
- Facilitates/assures process for managed care authorizations post admission, reviews contracts for compliance, and seeks carve-outs and appropriate levels of authorized care.
- Oversees or directly participates in the triple check process with administration, rehab, and business office staff to ensure accuracy and regulatory requirements are met prior to billing.
- Meets with rehabilitation director and personnel regularly to ensure documentation compliance and accuracy.
- Facilitates Utilization Review meetings or assigns designee.
- Identifies recurring problems and communicates to appropriate staff for resolution.
- Provides support for state and/or federal surveys, as needed.
- Oversees the tracking system of MDS schedules (timeframes and due dates)
- Seeks knowledge/clarification related to reimbursement regulation and MDS completion.
- Takes initiative to analyze the CASPER for potential areas of opportunity to improve clinical outcome measures for the Five-Star Report and other clinical indicators. Works with the interdisciplinary team to develop action plans for improved capture of MDS documentation.
- Works to implement strategies to optimize Keswick's CMI as a reflection of documented services provided.
- Prepares quality assurance reports and interprets/analyzes data for quality assurance purposes.
- Ensures timeliness of compliance with external audits, i.e., Telligen, pre/post payment reviews.
- Ensures timely completions of 3871s, Continued Stay Reviews, etc.
What is required in this position?- Registered nurse, licensed and in good standing with the Maryland Board of Nursing, required.
- Resident Assessment Coordinator Certified (RAC-CT) certification is desirable.
- KNOWLEDGE OF: Resident Assessment Instrument (RAI) manual, nursing and rehabilitation practice and principles; applicable laws and regulations governing long-term care and/or sub-acute (short stay) care; reimbursement requirements; diseases, conditions and treatment therapies for the patient population; MDS coding and regulations; ICD-10 Coding; Rehabilitation coding; patients' rights and the nursing role in helping protect and enhance those rights; principles and requirements for documentation and medical record management; computerized healthcare systems and medical records systems. Must be able to read, write, and understand the English language.
- SKILL IN: Using MDS computer program; PointClickCare (PCC) and Microsoft Office software and other software; communicating with other care providers, and administrative officials; effective listening and critical observations and utilizing the information for effective problem solving; relating to and working with the elderly, ill, disabled, recovering, emotionally upset and at times hostile people with tact and sensitivity.
What makes Keswick unique?Our vision is for greater fulfillment and freedom of choice in aging, for all. Committed to enhancing the quality of life for the guests and residents it serves, Keswick provides various award-winning services that enhance their lives and get them back to doing what they love.
